Thursday February 23rd 2017

U.S. Supreme Court takes up ACA

ANA and nurses are crucial to keeping health care reforms rolling

The American Nurses Association (ANA) has a long and strong tradition of working for vulnerable patients’ access to preventive services and cost-effective, quality care. And ANA and nurse members did not let up on their health care reform efforts even as the U.S. Supreme Court began hearing arguments on the Affordable Care Act (ACA) in late March.

ANA and nurse members demonstrated on the steps of the U.S. Supreme Court in Washington, DC, in support of the ACA. Concurrent activities included an online, daily analysis of the court proceedings; a Twitter chat in which nurses nationwide could pose questions about the ACA and arguments before the court; and participation in numerous media interviews. ANA also continuously updates helpful online charts and documents that describe its ongoing advocacy for RNs and patients as elements of health care reform are implemented. (To view ANA resources, go to

“ANA remains steadfast in support of the ACA, which increases access to care for tens of millions of people, and will strengthen and improve the health care system for generations to come,” said Cynthia Haney, JD, senior policy fellow in ANA’s Department of Nursing Practice and Policy.

ANA President Karen A. Daley, PhD, MPH, RN, FAAN, stressed that, “The law is designed to move us from a system that provides illness care to one that provides patient-centered and preventive health care, and that is what nurses do best. That’s why it’s so important that as the law’s provisions continue to be implemented, nurses are able to contribute all their skills and knowledge to the care of patients.”

What’s at stake

There are many parts of the law — such as care coordination requirements, workforce preparation, and the creation of accountable care organizations (ACOs) — that are not directly connected to or reliant on the issues argued before the court, Haney said.

“However these provisions, too, would be eliminated if the entire law is struck down,” she said. “So ANA is working quickly to help implement these critical aspects of the ACA that are aimed at patient safety and quality and developing a larger and better prepared workforce to deliver primary and preventive care services.”

For example, ANA has been working to ensure that RNs are fully included as leaders and eligible health care providers in new, patient-centered, team-based models of care, such as “medical homes” and ACOs. ANA is also urging that federal agencies identify advanced practice registered nurses as primary care providers, and that nurse-managed clinics qualify as “essential community providers” under state health insurance exchanges launching in 2014. (These state-regulated exchanges would allow individuals and small businesses to purchase affordable, health insurance coverage.)

“At the same time, some of these reforms to the delivery system — perhaps in different ‘flavors’ — will still develop independently of the ACA because of unavoidable economic pressure to improve the health care marketplace,” Haney said. “Even if the entire law is struck down, improved accountability, care coordination, and quality improvements will almost certainly be linked to how providers and health systems are paid. So it is more important than ever that the voice of registered nurses be heard throughout this process.”

Contesting several key points

The Supreme Court is expected to issue its ruling at the end of June, and it currently is difficult to predict how the law, or parts of it, will fare.  Back in March, justices heard oral arguments that concentrated on several key issues. The first focused on whether the time is even right to consider the constitutionality of the individual insurance mandate, because this ACA provision doesn’t go into effect until 2014. As a result of this timeline, no one currently has had to pay a penalty or has been “harmed” for not having purchased health insurance.  Most observers speculate that the court will not consider this an obstacle to their consideration of the other provisions in question.

The individual minimum coverage insurance requirement was a major point of debate. Questions from Justices Kagan, Breyer, Sotomayor, and Ginsberg appeared to support the government’s argument that everyone is part of the nation’s health care market and that requiring insurance coverage is a legitimate federal regulation of that market, according to an ANA analysis. Justices Alito and Thomas have been presumed to be opposed to the mandate from the start, and questioning from Alito during oral arguments seemed to confirm that viewpoint.

ANA filed an amicus brief to the Supreme Court in January supporting the minimum coverage mandate. It described RNs’ experience on the frontlines of care, and the damaging effects on individuals and families resulting from lack of access to health insurance.   If everyone contributes toward insurance, then the risks and costs will be spread fairly so all can have access to basic coverage and needed health care, according to Haney.  “This is the whole purpose of insurance pools.”

Another argument before the court focused on a provision that expands the Medicaid program. Under the ACA, the federal government beginning in 2014, would pay 100 percent of states’ increased costs for expanding Medicaid eligibility to those at 133 percent of the federal poverty level, which the Commonwealth Fund reported as about $14,400 for a single adult and about $29,325 for a family of four. The federal government then would gradually reduce the amount it pays to cover states’ additional costs to 90 percent by 2020. States refusing to comply with the expansion would lose 100 percent of their Medicaid funding.

The debate over this provision centers on some states’ contention that the provision is coercive and that Congress exceeded its authority by expanding eligibility requirements that states must adopt to be eligible to participate in Medicaid at all.

Some observers were surprised that this issue was even included in the court’s deliberations, since the federal government has routinely placed conditions on funds given to states for certain programs for many decades. For example, to obtain substantial increases in federal public education funding, states have to comply with “No Child Left Behind” requirements.  Similar “strings” are tied to billions of dollars in federal funds that go to states for transportation, housing, social services, and pollution control, among other purposes.

Another major issue put before the court focuses on “severability” — whether one part of the ACA can be ruled unconstitutional, such as the individual insurance mandate — while allowing the other parts of the law to stand.  As noted earlier, though, the private marketplace will continue to have strong incentives to pursue innovations that improve quality outcomes and allocate resources more efficiently. Regardless of the outcome, Haney said that health care reform must continue, and nurses are central to its success.

“Registered nurses must get involved in their professional organizations and practice settings to keep innovation and quality, cost-effective health care delivery moving forwarD — whether the law is there or not.”

Two nurses wait — and promote access to care — on Supreme Court steps

Giving up comfort and a decent night’s sleep, two nurse members waited in line overnight in front of the U.S. Supreme Court to have the opportunity to witness arguments for and against the Affordable Care Act. They also were able to share their perspectives on what health care reform means for patients and consumers to the many media who flocked there to cover the event.

Lauri Lineweaver, MSN, RN, CCRN-CSC, and Laura Brennaman, MSN, RN, CEN, are both fellows at the Robert Wood Johnson Foundation Nursing and Health Policy Collaborative at the University of New Mexico College of Nursing who recently interned at ANA.

“I have been following health care reform for years as a nurse and a consumer,” said Brennaman, a Florida Nurses Association member. “I worked in an ER for 30 years and saw that it was a safety net for many people who had no access to primary care. But using an ER for primary care is not cost-effective, and it also doesn’t allow for continuity of care that people need to stay or get healthier.”

Over the years, Brennaman’s passion for patients’ access to care led her to writing letters to policymakers and meeting with them in person. She also wanted to see the Supreme Court in action, and her recent internship in the metropolitan Washington, DC-area gave her that chance.

Lineweaver, a New Mexico Nurses Association member, is equally passionate about access to care and had the same desire to attend the court proceedings.

“New Mexico is a poor state,” said Lineweaver, who works as a clinical educator at a large health care facility. “Thirty-one percent of people in my state have no insurance, and very few have private insurance. We see a lot of people with chronic diseases, and they generally have poor health care outcomes because they don’t have access to preventive screenings and other follow-up primary care.

“Chronic diseases don’t go away, because people don’t have insurance. And one way or another, these costs for their care have to get paid.”

Lineweaver also strongly supports the workforce development provisions within the ACA.

There currently is a shortage of nurses and other health care providers in most of the rural areas of New Mexico, and new projections show a huge national shortage on the horizon, she said.

Engaged in the experience

While waiting in line that Sunday, Brennaman was surprised by the size and sounds of the crowds who came to demonstrate in favor of or against the ACA. She also found herself giving 40 to 50 interviews to the media.

“They wanted to talk with me because I was a nurse,” she said.

Lineweaver also participated in media interviews and blogged for RWJF about the many homeless and working poor who were being paid $5 an hour to hold other people’s places in line. (Only 60 people could get into the courtroom on any given day.)

“I realized that these are the people we are trying to help, who would benefit from having access to preventive care and management of their chronic illnesses,” Lineweaver said. “They are really hanging by a thread, and that is why it is so important that ANA and nurses continue to fight for affordable, quality health care.”

Once inside the court, both nurses felt the history and gravity of the court proceedings. On that day, the arguments before the justices focused on whether it was premature to be addressing the case since no one had been penalized for not complying with the individual insurance mandate.

Both Lineweaver and Brennaman also joined ANA staff and other nurses in a demonstration March 24 in front of the court building.

Said Brennaman, “I’ve seen too many people who have asthma, heart disease, and diabetes require emergency care that could have been prevented if they had access to routine primary care services. I’ve also seen a young mother die from appendicitis, and heard about a man who may sustain long-term renal damage because he couldn’t get treated for a kidney stone. None of this should happen.

“I wish we could put aside any divisiveness about the law and agree that we should all want to see people healthy.”

— Susan Trossman is the senior reporter for The American Nurse.

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